Breast self-examination: Knowledge, practice and associated factors among 20 to 49 years aged women in Butwal sub-metropolitan, Rupandehi, Nepal

Background Breast cancer is the second most common cancer in the world and also among Nepalese women. Breast self-examination is an important, cheap, and easy method for early diagnosis of breast cancer which can be cured in the majority of cases if diagnosed in the early stages. In developing countries like Nepal where the awareness regarding breast cancer and breast self-examination is poor, breast cancers are diagnosed at late stages resulting in a poor prognosis of the disease. The study assessed knowledge, practice, and factors associated with breast self-examination. Methods A cross-sectional survey was carried out among 262 women in the Butwal sub-metropolitan adopting multi-stage sampling. A pre-tested structured interview schedule and an observation checklist were used to collect the data. Data was entered in EPI-data and necessary univariate, bivariate, and multivariate analyses were done in SPSS. Results The study found that more than half of the participants (55.3%) had poor knowledge of BSE. Only one-fourth (27.1%) of them were practicing BSE and among them, most of them (93.0%) had poor practice. The factors such as ethnicity from Brahmin/Chhetri [AOR = 2.099, 95% CI (1.106–3.981)], use of contraceptive devices [AOR = 9.487, 95% CI (2.166–41.558)], personal history of breast lump [AOR = 12.502, 95% CI (1.639–95.387)], family history of breast cancer [AOR = 5.729, 95% CI (1.337–97.512)], and knowledge of BSE [AOR = 4.407, 95% CI = 2.160–34.650)] were significant determinants of BSE practice among 20–49 years women. Conclusion The study concluded that most of the women had poor knowledge and practice of breast self-examination. The study also indicated the influence of ethnicity, contraceptives, personal and family history of cancer/early warning signs, and knowledge for practicing breast self-examination. There is an immediate need to increase the knowledge and practice of breast self-examination to prevent and detect breast cancer in its early stage.


Introduction
Breast cancer is a type of cancer that grows from breast cells and therefore the development starts from the inner lining of milk ducts (ductal carcinoma) or the lobules that offer milk (lobular carcinoma) [1]. It is the leading cause of cancer mortality among women in the world [2]. It's the second commonest cancer among women in Nepal that is commonest in urban settings. It's additionally common among young premenopausal women and plenty being diagnosed at a sophisticated stage [3]. Risk factors of breast cancer in Nepal are nulliparity or late age at first childbirth (>35 years of age), family history, smoking, excessive alcohol consumption, consumption of fat (BMI�30Kg/M 2 ), and exposure to radiation and hormone replacement therapy [4].
BC is the most common cancer in females, in both developing and developed countries, with an estimated 297,790 new cases and 43,170 deaths in the United States in 2023 [5]. There were an estimated 2.1 million newly diagnosed female breast cancer cases and 600 thousand breast cancer-related deaths occurred in 2018 [6]. In women, BC is the most commonly diagnosed cancer (11.7% of total cases) and the leading cause of cancer death (6.9%) in 110 countries among the 185 countries. It is the leading cause of global cancer incidence in 2020, with an estimated 2.3 million new cases, representing 11.7% of all cancer cases. It's the fifth leading cause of cancer mortality in the world, with 685,000 deaths [7]. It accounts for one in four cancer cases and one in six cancer deaths, ranking first for incidence in the vast majority of countries (159 of 185 countries) and mortality in 110 countries [7]. In Nepal, according to the data from seven major cancer service hospitals in 2012, BC was the second most common cancer among women, after cancer of the cervix. According to GLOBOCAN 2012, an estimated 1,700 new BC cases were diagnosed in Nepal in 2012 with an age-standardized rate (ASR) of 13.7 new cases per 100,000 women, while 870 fatalities in women occurred with an ASR of 7.2 cases fatalities per 100,000 women [4]. GLOBOCAN 2018 estimates of cancer incidence and mortality, 2018 an estimated 2068 new BC cases were diagnosed in Nepal, with an ASR of fifteen cases per 100,000 women, whereas 1018 deaths occurred with an ASR of 7.6 cases per 100,000 women [8].
Early detection of breast cancer can reduce its morbidity and mortality. Mammography, clinical breast examination (CBE), and breast self-examination (BSE) are considered to be effective strategies for the early detection of breast cancer [9]. BSE is a patient-centered, cheap, and non-invasive method of screening for breast cancer, which improves the chances of early BC detection [2]. It's a process whereby women examine their breasts frequently to detect any abnormal swelling or lumps to seek prompt medical attention. It's one of the screening strategies used to detect breast-related issues like possible lumps, distortions, or swelling. BSE is usually recommended for each woman higher than the age of 20 years to be done for 20 minutes once monthly, between the seventh and tenth days of the menstrual cycle (2-3 days after the menses has gone), and goes an extended manner in detecting breast [10]. Early diagnosis has a positive impact on the prognosis and limits the development of complications and disability. It will increase life quality and survival [11]. In BSE, the patient observes and palpates their breasts and accessory anatomical structures to detect changes or abnormalities that will indicate the presence of cancer. Throughout the palpation of the breasts and adjacent structures (nipples, areolas, and axilla), lymph nodes and condensations also suggestive of neoplasias can be noticed [12]. Although BSE alone is not sufficient for early detection of breast carcinoma, it is still a very important screening tool for early detection of carcinoma in developing countries, because it is cheap, widely available, and doesn't need complicated technical coaching, hospital visits, and specialized instrumentality [9]. BSE in conjointly with screening mammography is presently advocated by several organizations, and it's also conjointly suggested for younger women beginning in their 20s who are nevertheless being screened by mammography [13]. Performing BSE is one method for a woman to understand how her breasts commonly feel so that she will notice any changes that do occur. Women who perform BSE monthly and properly are more likely to detect a lump within the early stage of its tumor. Evidence showed that comprehensive knowledge of BSE remains low in several developing countries [13].
This study aimed to assess knowledge, practice, and factors associated with breast selfexamination among 20-49 years aged women in Butwal Sub-Metropolitan.

Study design
The study design was cross-sectional.

Study method
The study method was quantitative.

Study setting
This study was conducted in the Butwal Sub-Metropolitan, Rupandehi district, Lumbini Province of Nepal. Since breast cancer is the most common cancer among women in urban settings [3], the Butwal sub-metropolitan is an urban area where the study on breast cancer and breast self-examination was inadequate.

Study population
The study population was women aged 20 to 49 years who are currently residing in the Butwal Sub-Metropolitan of Rupandehi district as BSE is recommended to start from the age of early 20 and breast cancer is more common in young pre-menopausal women.

Sample size
The prevalence of BSE practice in Butwal was 19.2% [14]. The required sample size was calculated with an assumption of 95% confidence interval (CI) & 5% maximum allowable error (d), the prevalence (p), and the population of 20-49 years women from the selected wards (N).
Using the sampling formula, Here, n = required sample size, value of z at 95% confidence level = 1.96, d = 0.05, p = 19.2% = 0.192, q = 1-p = 1.0-0.192 = 0.808, and N = 22,332. Putting these values in the above formula we got n = 235.87 (n� 236) and adding a 10% non-response rate, the final sample size for the study was 262.

Sampling procedure
Multi-stage sampling technique was used for this study. In the first stage, among 19 wards of Butwal Sub-Metropolitan, 6 wards (33%) were selected randomly by simple random sampling. In the second stage, the required number of participants was identified based on proportionate sampling (Table 1). In the third stage, the participants to be included in the study were selected using systematic random sampling. The first household was selected by choosing a random number from 0 to 9. Another random number from 0 to 9 was selected for determining the interval. In a selected household, if there were more than one eligible woman then the participant with the highest age was chosen.

Selection criteria
Inclusion criteria.
• Women of age between 20 to 49 years who were residing in the Butwal sub-metropolitan of Rupandehi district, Lumbini Province Nepal, and provided consent to participate in the study.
• Those women of age between 20 to 49 years who were unable to respond due to severe physical and mental problems.
• Those women had a history of breast cancer or mastectomy.

Ethical considerations
Ethical approval was obtained from the Institutional Review Committee, Pokhara University with reference number 11/078/079. Permission was also taken from the Butwal Sub-Metropolitan. Participants were fully informed about the objectives and purpose of the study before the data collection. Both verbal and written consent was taken. Confidentiality and privacy were maintained properly. The right to refuse to take part in the study was highly respected.

Research tools and their development
A pre-tested structured interview schedule and an observational checklist were used for data collection. It was developed after an extensive literature review and consultation with experts. The interview schedule included socio-demographic factors, gynecological and obstetric factors, knowledge, and self-reported practice of BSE.
Socio-demographic factors were age, marital status, religion, ethnicity, occupation, education, and household average monthly income. Gynecological and obstetric factors were age at marriage, parity, breastfeeding, contraceptive use, personal history of breast lump, family history of breast cancer, and mastectomy in the family.
Knowledge of BSE was assessed by self-constructed 10 multiple choice questions with three wrong and one right option on different dimensions of knowledge of BSE (see respective table in results for questions). Responses of the participants were categorized into 1 and 0 for right and wrong answers respectively and the mean knowledge score was calculated. Participants who performed below the mean score were classified as having poor knowledge and those who had mean or above mean were classified as having good knowledge of BSE.
Self-reported practice related to BSE was measured by self-constructed 14 different questions included in the interview schedule (see respective table in results for questions).
To observe the practice of BSE, an observation checklist was adopted from an Iranian study [15]. A female dummy was taken during the data collection to observe the steps of breast selfexamination among those who practice. Twenty-two steps (see respective table in results for questions) were observed considering the dummy privately in a quiet room during the observation for breast self-examination practice. Participants were asked to show the steps on a dummy on how they performed breast self-examination. The scores ranged from 0 to 22 and each step was ticked if found to show in a dummy. The results were determined as good (15)(16)(17)(18)(19)(20)(21)(22), medium (9)(10)(11)(12)(13)(14), and poor (0-8).

Pretesting, validity, and reliability
Pre-testing was done in a similar setting on 10% (26) of the sample size excluding the study area and changes were made accordingly. The interview schedule and observation checklist were designed based on the reference to various research papers. The data collection tool was made in simple, clear, and Nepali language. The research guide and experts were consulted for appropriate suggestions on design and tools. The researcher herself was involved in data collection and analysis. The validity and reliability were confirmed by the supervisor, experts, and pre-testing.

Data collection procedure
Data were collected through face-to-face interviews and observation methods between April-May 2022. A structured questionnaire was used for the interview and an observational checklist for observing BSE practice. A female dummy was taken during the data collection to observe the steps of breast self-examination among those who practice. Data was gathered in the prescribed format. The interview was conducted after taking both verbal and written consent. The objective and purpose of the research were clearly described before taking consent. Confidentiality was also maintained. The Nepali language was used to collect the data and data collection was carried out following precautions against COVID-19.

Data analysis
Epi-Data software was used for data entry and analysis was performed with the help of the Statistical Package for Social Science (SPSS). Descriptive statistics (i.e. frequency, percentage, mean and standard deviation) were applied to describe the study population. Pearson's Chisquare test was used to find out the association between dependent and independent variables i.e. association between the practice of BSE and socio-demographic, gynecological & obstetric, and knowledge-related factors. Bivariate logistic regression analysis was used among the associated factors. Multivariate logistic regression analysis was used to assess the predictors for the practice of BSE.
Gynecological and obstetric information. More than half of the participants were married (59.3%), had �2 children (50.6%), and didn't use any contraceptives (58.1%). Moreover, 13.4% had a history of breast cancer, and 6.5% and 4.2% had a family history of breast cancer and mastectomy respectively. Almost half (50.0%) had heard about BSE and the main source of information about BSE was the internet (46.6%) followed by healthcare providers (42.7%) respectively ( Table 3).
Knowledge of BSE. Out of the 262 participants, more than half of them (55.3%) had poor knowledge of BSE (Table 4).
The self-reported practice of BSE. Based on the self-reported practice among 262 participants, only 27.1% of participants were practicing BSE in the last twelve months. However, among 27.1% who were practicing, only 59.3% started at the correct age, 36.6% were practicing BSE at the right frequency, and 53.6% were performing at right time. However, nearly all (94.4%) of them reported they were examining both breasts ( Table 5).
The practice of BSE on observation. However, the practice of BSE on observation on a female dummy revealed that nearly all of them have a poor practice of BSE (93.0%) ( Table 6).

Bivariate analysis
Among the socio-demographic variables, the result showed that age, education, family type, occupation, household average monthly income, and marital status were significantly associated with the practice of BSE in Parson's chi squire test (p<0.05) ( Table 7).
Among the gynecological and obstetric variables, age at marriage, number of children, use of contraceptive devices, personal history of breast lump, family history of breast cancer, and family history of mastectomy were significantly associated with the practice of BSE in Parson's chi squire test (p<0.05) ( Table 8).
Moreover, the result showed that the level of knowledge was significantly associated with the practice of BSE (p<0.05) ( Table 9).
The strength of the association of statistically significant factors with the practice of BSE in bivariate analysis logistic regression analysis is presented below (Table 10).

Multivariate analysis
On multivariate analysis after adjustment of covariates, participants from Brahmin/Chhetri ethnicity were two times more likely [AOR = 2.099, 95% CI (11.106-3.981)] to practice BSE as compared to others. Participants who use contraceptive devices were nine times more likely [AOR = 9.487, 95% CI (2.166-41.558)] to practice BSE as compared to those who didn't use it. Participants who had a personal history of breast lumps were twelve times more likely [AOR = 12.502, 95% CI (1.639-95.387)] to practice BSE as compared to those who didn't. Participants who had a family history of breast cancer were five and half times more likely [AOR = 5.729, 95% CI (1.337-97.512)] to practice BSE as compared to those who didn't have. Furthermore, participants who had good knowledge were about four and half times more likely [AOR = 4.407, 95% CI = 2.160-34.650)] to practice BSE as compared to those who had poor knowledge (Table 11).

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Breast self-examination: Knowledge, practice and associated factors among women

Discussion
The finding of this study indicates that most of the reproductive age group women had poor knowledge of BSE. Only 44.7% had good knowledge of BSE. A similar study conducted at Rapti Sonari Rural Municipality, Banke District showed about the same proportion of women had good knowledge (44.3%) [16]. Similarly, other studies conducted in Ghana (43.3%) [13], Southwest Ethiopia (30.0%) [10], and Southwest Cameroon (25.4%) [17] also reported less proportion of having good knowledge of BSE. The reason for the difference in knowledge in

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Breast self-examination: Knowledge, practice and associated factors among women Table 4. Knowledge-related information (n = 262).

PLOS ONE
Breast self-examination: Knowledge, practice and associated factors among women different studies from different countries might be due to the difference in the study setting and sociocultural factors across the world. Moreover, the current study also showed that 27.1% of women were practicing BSE. A similar study in the Banke district of Nepal showed 19.6% of women were practicing BSE [16]. Similarly, studies conducted in the South district of Ghana (27.5%) [13], Tabriz, Iran showed (18.8%) [15], and Northwest, Ethiopia (32.5%) [18] showed a lower proportion were practicing BSE. However urban women of Shah Alam, Malaysia higher (55.0%) % of women were practicing BSE [19]. Studies from various countries showed somehow differences in the practice of BSE. The reason for this might be due to the difference in knowledge of study participants and the difference between study areas.
In observation, none of the women had good practice of BSE in this study. A similar study conducted among women in Tabriz, Iran showed performance of practice was very poor among 22.7%, poor among 46.7%, medium among 21.3%, good among 6.7%, and very good among 2.7% (17). It indicates that even though some women have knowledge of BSE and practice it, however, they aren't practicing following the appropriate technique.
After The finding of the current study showed ethnicity as a significant determinant for practicing BSE which in contrast with the study conducted among women of reproductive age of Rapti Sonari rural municipality, Banke district, Nepal that there was no significant difference [16]. This contrasting finding might be due to the differences in knowledge in different ethnic groups living in the two study settings.
Similarly, the current study showed the use of contraceptive devices as a significant determinant for practicing BSE which showed a contrast finding with the study conducted among women who attended primary health care, in Kuwait that there was no significant difference in BSE practice regarding the use of contraceptive devices [20]. This contrasting finding might be due to the reason that those who use contraceptive devices get health education regarding reproductive health and disease from the health institution.
Likewise, the current study revealed that personal history of breast lumps is a significant determinant for practicing breast self-examination (AOR = 12.505, 95% CI = 1.639-95.387). The finding of this study is supported by the study conducted in Ethiopia in 2018, where women with a personal history of breast problems were 3.27 times more likely to practice BSE [21]. This finding is also supported by another study conducted in Iran in 2018 [22]. This might be the reason that one with a breast lump or disease gets information and advice from the health institution and are conscious about their health disease. Furthermore, the finding of this study revealed that a family history of breast cancer was also a significant determinant for practicing BSE (AOR = 5.729, 95% CI = 1.337-97.512). The finding of this study is supported by different studies [18,23,24]. This could be due to the reason of getting information and advice from health care providers and being aware as  they might be at risk for breast cancer, so it can be detected earlier with breast selfexamination.

Conclusions
The study concludes that most of the women had poor knowledge. Also, very few women were practicing breast self-examination. Among those who were practicing breast self-examination, almost all of them demonstrated poor practice. Moreover, the study also concludes that ethnicity, use of contraceptives, personal history of breast lump, family history of breast cancer, and level of knowledge have a significant influence on practicing breast self-examination. There is an immediate need to increase the knowledge and practice of breast self-examination to prevent and detect breast cancer in its early stage.

Limitations
The study was carried out in selected wards of the Butwal sub-metropolitan of the Rupandehi district of Nepal and therefore, it might not be representative of the entire country. Likewise, the proportion of women practicing BSE in this study was assessed by a self-reported response regarding whether they have been practicing BSE in the last year or not. Other aspects of the practice such as frequency, timing, process, etc. of BSE weren't considered while determining the factors associated with the practice of BSE.